The Los Angeles Times reports that our nation’s physicians’ irresponsibility is a primary reason why more people are dying from opioid overdoses in this country right now than are dying in traffic accidents.
Doctors are fueling the nation’s prescription drug epidemic and represent the primary source of narcotic painkillers for chronic abusers, according to a new government study.
The finding challenges a widely held belief that has long guided policymakers: That the epidemic is caused largely by abusers getting their drugs without prescriptions, typically from friends and family.Dr. Tom Frieden, director of the Centers for Disease Control and Prevention, which conducted the study, said the research showed the need for greater focus on doctors who are “problem prescribers.”
The study, published Monday by the Journal of the American Medical Assn., echoes a 2012 Times investigation that found drugs prescribed by doctors caused or contributed to nearly half of the prescription overdose deaths in Southern California in recent years.
The Times also revealed that authorities were failing to mine a rich database of prescribing records to identify and stop reckless prescribers.
Frieden said the new study, appearing in JAMA’s Internal Medicine journal, along with The Times investigation and a second JAMA article on the widespread use of narcotic painkillers in Tennessee, all showed that physician prescribing was a key contributor to the crisis of addiction and overdose that has continued to mount since the CDC declared it an epidemic in 2011.
Prescription drugs — mostly narcotic painkillers, such as OxyContin and Vicodin — contribute to more than 16,000 fatal overdoses annually and are the main reason drugs have surpassed traffic accidents as a cause of death in the U.S.
Now, obviously, it’s a problem when a “bad apple” doctor decides to facilitate a patient’s opioid addiction to make an extra buck. But I think the problem is quite a bit deeper than that. There are many, many physicians who are inadvertently creating heroin addicts and causing fatal opioid overdoes without the slightest intention of doing their patients any harm. The problem, as I see it, is that the medical community is not sufficiently aware of how significant of a percentage of people are at risk of developing an opioid addiction if they are prescribed vicodins or percocets or oxy-contin. People are routinely given these medications after relatively minor surgery or dental work. But somewhere around 6% of the people prescribed these drugs are likely to become addicted to them.
The overprescription of these drugs also means that high schools and colleges are absolutely awash with them, and they’ve become a staple of the drug culture commonly taken at weekend parties to supplement the alcohol and marijuana. Most kids can take these drugs without any problem, but about one in twenty of them will wind up addicted to opioids. That may seem like a small number, but if one of every twenty kids who drank on the weekend wound up dying in an automobile accident, the casualty rate would be catastrophic.
I’ve posted about this repeatedly and I’ve provided many links to anecdotal stories. I can’t count how many times I’ve read stories about kids who overdosed on opioids who started out using drugs prescribed by a doctor. Tonsillitis can be a death sentence. Getting your wisdom teeth out can be a death sentence. Having you gall bladder removed can be a death sentence. I’ve seen all of those examples. Those doctors weren’t aware that, when they prescribed a post-operative painkiller, they were going to kill their patients. But that is what they did.
So, yes, we need to crack down on doctors who are corrupt, but we also need to educate honest doctors about the harm they are doing.
And we need someone to develop non-addictive painkillers.
BigPharma is at fault on this too. The more stuff doctors prescribe, the more BigPharma sells.
their solution is more drugs. Look up Suboxone, for example.
Less addictive painkillers would be great but might be only one of the ways to tackle the problem, and possibly one of the harder ways.
Other thoughts… better genetic and psychological screening for people at high risk of addiction. Better follow-up once the meds are prescribed. Better screening for the diagnosis of addiction (a lab test?) so cases are caught and referred early, and more of the same isn’t prescribed. Better pain scoring so highly addictive opioids aren’t prescribed to patients experiencing mild pain. Sustained release injectable pain medications that patients can’t give or sell to others.
Not my field at all, but there’s probably technology in existence now that could help in a fairly short time frame.
The inherent problem in developing non-addictive painkillers is that you are working working with a limited set of receptors in the nervous system – most important for severe pain are the opioid receptors. Unfortunately anything that binds those receptors is going to be addictive. There are multiple other pain control mechanisms that are adequate for mild pain, or can be used to complement opioids and so reduce the dose of opioid you need. But getting around the addictive quality of that receptor strikes me as a super hard and long-term problem. 🙁
Yes. And about 10-15% of ANY group you pick will have an addictive response to ANY meds that bond to these receptors. The receptors are evolutionarily-conserved and have been present in vertebrates for hundreds of millions of years. Not gonna go away any time soon. An easy solution would be to QUIT PRESCRIBING OPIATES FOR TOOTHACHES, ETC. Here in Ky. the legislature/medical board finally got around to severely restricting opiate prescribing, and now we have a heroin “epidemic”.
I never hear any school anti-drug programs highlighting percocet as a “gateway drug”; they just go nuts over marijuana. I wonder why?
there is no reason to put it in parentheses. Your epidemic is real.
But, for practical purposes, an oxy-addict is just as likely to steal, lie, turn blue, and die as a heroin addict. The only real added risk with heroin is related to purity issues and dose variability, and the risks (HIV, Hepatitis) associated with needles. But the opioid addiction is the exact same, and just as likely to kill.
There are undoubtedly genetic components to response to opiates. There is strong evidence that genetic factors are important here. The notion of the “addictive personality” may well be the “addictive genetic susceptibility”.
I’m sure tort reform would fix everything.
is the pain-relief specialty.
If you become a physician specializing in pain relief, you are in great risk of going to jail. But yet many pain situations are very intractible.
The problem is that pain, like beauty, wine appreciation, hallucinations, or odor perception, is entirely internal, and not subject to external verification. This means that if you go and say that the prescription did not solve your pain and you need more, there is no external verification. And that is a problem for the physician and for the patient.
There are physical components to pain. If there weren’t, opioids wouldn’t work. Because mu-opioid receptors exist in the spinal cord to modulate the perception of pain coming from peripheral c-fibers. That’s how the painkilling component of opioids works.
There are also mu-opioid receptors in your brain (which is where the euphoria comes from) and in the intestinal tract (which is how loperamide/Immodium AD) works.
The number one cause of death is “The War on Drugs”.
What’s needed is a sane drug policy, which we will never have as long is there is profit motive.
Everything else is BS. I wrote a paper in 1990 for an argumentative writing class on legalization, treatment and drug policy. It has gotten progressively worse in the 24 years since.
Not sure what your prescriptions, so to speak, wrt doctors is. What do you expect them to do?
Prescription*
It’s not accidental. If a drug is addictive, the company will sell more of it. These opiate drugs are HUGE profit centers for the companies, because it’s hard to stop taking them, and they have enormous patent-fueled margins.
Remember companies are run by psychopaths (because that’s what it takes to get to the top of the corporate ladder). The CEO’s making decisions about research allocations are thinking about and actively hoping for addictiveness. They may have the sense to not talk or write about it, even in private, but they are certainly thinking about it. Now they don’t want dead customers, but hey, break eggs to make omelets and all that.
The move to more lax painkiller use was driven by some research in the ’90s which showed that more generous use didn’t raise the addiction rate. I haven’t reviewed it lately, but it seemed honest at the time. It was mostly short-term prescriptions for severe pain (the one I remember was about post-op recovery in the hospital). It might well have been underpowered – if “only” 15% of the population is in danger of being easily addicted, and only 20% extra get caught up by some particular prescribing regimen, then you’ve got an effect of 3%, which needs a pretty big study to catch reliably.
It would be interesting to look at the funding for those sources, and for the op-eds I remember reading talking about undertreatment of pain. I thought they were very reasonable at the time, but I’ve changed my mind with the staggering increases in prescription drug deaths.
CDC Report.
The facts aren’t encouraging.
Interesting that the CDC chose to report the tripling of the overdose death rate from 1990-2008, but used 1999 instead of 1990 as the baseline for sales of prescription painkillers. Did the CDC not have the data from 1990? Or did increased sales since 1990 not fit as neatly with the narrative of 3X sales = 3X overdoses?
In our neo-liberal economic stage, those sales support Big Pharma which in turn supports investors and pension plans. That is not going to be shut down. Therefore, blaming physicians and prescription drug addicts is one part theater for the rubes and one part propaganda and advertising for the drug addiction treatment industry.
The increases in the sales of prescription painkillers may slow down but expect it to continue increasing. A predictable negative consequence (or collateral damage) of the PPACA
The adult population of Medicaid beneficiaries (those without qualifying dependents) under the PPACA will increase substantially. How the other newly insured PPACA groups will behave is undefined.
I’ll go with “not fit the narrative”. So most likely the OD rate didn’t go up as much as the prescription rate.
It’s very possible opiate painkillers were underprescribed in 1990. The rules used to be pretty strict. Just because they’re badly overprescribed today doesn’t means they’ve always been overprescribed.
There were plenty of “Dr. Feelgoods” long before 1990. The difference between than and now is twofold. 1) Far less regulation and control of addictive painkillers. 2) A higher percentage of the population can afford those painkillers (a by-product of expanded health insurance coverages and a higher proportion of the population insured).
I’m not inclined to conclude that there has been an increased rate of over-prescription based on the reported information. Would need to know the stats on the group(s) that had both a “Cadillac” health insurance plan and significant disposable income before 1990 and today. The change we’re seeing may be nothing more than the “middle class” able to behave more like the upper middle and upper class.
Need to amend “The change we’re seeing may be nothing more” to “Excluding group of Medicaid beneficiaries, the change …”
Until the PPACA, there wasn’t much change in the population of Medicaid eligible. There was, however, a significant change in its management under Clinton. Beneficiaries were allowed more choice in selecting providers and outsourcing the payments for medical services to private companies either began or greatly expanded. Would it be surprising that doctors working in public clinics and hospitals were more cautious and prudent in prescribing addictive painkillers than the doctors working in private facilities?
It was doctors that Maggie Kuhn (founder of Gray Panthers) had in mind when she said:
Young and old even have the same drug problems: `The pushers are different, but both are addicts.’
http://newint.org/features/1982/06/01/still/
And she was seeing that in the 70s and 80s.
Acting like this is some “Big Pharma” conspiracy is stupid. These drugs are all off-patent, which means that no individual company is making giant $$$ off this. In fact, it’s being sold by generic pharma companies, which do no advertising nor any R&D. There is certainly plenty of money to be made, but it’s chopped up amongst many companies, and it’s a high-volume low-margin (for pharma) kinda business.
Except the stockholders of name brand pharmaceutical companies don’t differ much from the stockholders of generic pharmaceutical companies. For laypersons like me, Big Pharma includes the Merck’s and the Teva’s.
Also, since I’m a physician (though I do not prescribe opioids), I’ll ask you to try imagining what this looks like from the doctor’s perspective. They are pushing us to see more and more patients, and paying us less and less to do it. We have piles of paperwork, phone calls, forms, and refills that suck up hours of every day for which we don’t get paid a nickel. Add to this the fact that we are about to be rated by patients, and that rating will, in the near future, impact our reimbursement.
Combine with the fact that, as one poster mentioned above, pain is purely subjective and non-verifiable, and the path of least resistance is pretty clear: you give them the scrip and go about your day.
Mind you, I’m not saying this is a good thing. But it’s also not something that is amenable to any simple solution. There are other pain medications, but they are either nowhere near as strong, or they can be taken for only a few days. So opioids are going nowhere anytime soon.
I’m not particularly empathetic with physicians about the administrative burden and assembly line patient care foisted on them by health insurers. Frances Perkins, Harry Truman, and others did everything they could to bring UHC to the US, but those efforts were defeated by physician groups, principally the AMA.
Economically, it’s a waste of health care resources to have doctors, nurses, PAs spending less time with patients and more time filling out paperwork. But that economic drag seems not disturb many. Not even physicians who seem only interested in reducing their paperwork/administrative burden through electronic health records and a smaller group that wants it reduced further with single-payer health insurance programs. The latter would be better than what we have today, but isn’t a panacea and would only moderate some of the dysfunction in the US health care system. It would remain twice as costly as that in other advanced industrial/service economies.
Probably unfair to accuse a physician posting to BoomanTribune of the opposition to UHC that took place in a previous generation. 🙂
My comment wasn’t directed as scottso but at the US physician communities in general. (Note that I tipped both of her/his comments.) It’s only recently that any sizable physician group has stepped up and championed any substantive, progressive, governmental health care policy change.
The question is, which doctors are overprescribing opioids, and for what causes? Is the distribution normal, or is there a skew?
I’m not really that opposed to opioid painkillers. Taken with the appropriate amount of caution, they are pretty safe. One dangerous aspect is that they are enhanced (poisoned) with the addition of acetominophen. That is an absolutely depraved policy in my book, and the FDA has begun to correct it by cutting the maximum allowable dose.
In my opinion, there should be no mixed medicine pills. That includes multi-symptom over the counter meds. People should know exactly what they’re taking.
The policy in question — I forgot a sentence — is the addition of acetominophen to prescription painkillers to deter abuse.
One last post for reference:
LD50 = the lethal dose for 50% of animals in a given study
LD50 for oral hydrocodone is 375 mg/kg in rats
LD50 for oral acetominophen is 1950 mg/kg in rats
Composition of vicodin is 5 mg hydrocodone, 500 mg acetominophen.
But here’s the thing with acetominophen; it sneaks up on you. And you don’t need to get anywhere near the LD50 to kill some people. This American Life actually did an excellent report on this very subject. I recommend you listen to it.
And this is only beginning to be acknowledge forty years after acetaminophen was introduced and championed as the better and safer pain medicine. If casual use of OTC acetaminophen preparations are also harmful, will that ever be known?
Is, and already is known.
Again, I recommend the TAL episode. Here’s the link.
http://www.thisamericanlife.org/radio-archives/episode/505/use-only-as-directed
Meant harmful to those that only “use as directed.”
I might have gotten lucky because after falling for the early adverts that it was safer and better than aspirin, I tried Tylenol for a headache a few times and it didn’t work. At the time it seemed as if it made the headache worse. That was probably the consequence of the headache being untreated and not a side-effect of the non-effective Tylenol. As aspirin was effective me, it seemed not to matter if Tylenol was ineffective or aggravated my headaches.